Ethekwini RevenueManagemement 251 - Durban

1 AR/01 v02/17 Ethekwini RevenueManagemement Florence Mkhize Building 251 Anton Lembede Street Durban 4001 Tel: 031 324 5000 Fax: 031 328 1002 E-Mail: Website: APPLICATION FOR REFUND PLEASE INDICATE WITH AN X, THE ACCOUNT(S) FOR WHICH A REFUND IS BEING APPLIED FOR CONSOLIDATED BILL Account Number:_____ WATER Account Number: _____ ELECTRICITY Account Number: _____ RATES Account Number: _____ TENDER DEPOSIT Ref : _____ METER APPLICATION Ref: _____ OTHER Specify: _____ PARTICULARS OF APPLICANT ACCOUNT HOLDER OTHER Specify: _____ If other, please provide details. For example, if a Conveyancing firm makes application for a refund, this must be _____ FULL NAME AND SURNAME: _____ _____ PHYSICAL ADDRESS: _____ _____ POSTAL ADDRESS: _____ _____ POSTAL CODE: _____ ID/SMART CARD NO (where applicable _____ TELEPHONE (B): _____ TELEPHONE (H): _____ CELL: _____ EMAIL/FAX: _____ REGISTRATION NUMBER OF JURISTIC PERSON (where applicable): _____ NB: PLEASE ATTACH A COPY OF YOUR ID/SMART CARD DOCUMENT OR PASSPART AS NO REFUNDS WILL BE ISSUED WITHOUT THEM.)

2 IN THE CASE OF A PROXY/REPRESENTATIVE OF A JURISTIC PERSON, ALL SIGNATURES TO THIS APPLICATION FORM MUST BE VERIFIED BY THE OFFICIAL STAMP OF THE JURISTIC PERSON. PLEASE COMPLETE IN BLOCK LETTERS AR/01 v02/17 Ethekwini RevenueManagemement Florence Mkhize Building 251 Anton Lembede Street Durban 4001 Tel: 031 324 5000 Fax: 031 328 1002 E-Mail: Website: APPLICATION FOR REFUND PLEASE INDICATE HOW YOU WISH TO RECEIVE YOUR REFUND DECLARATION/CONDTIONS 1. I/we the undersigned, hereby authorise and instruct the Ethekwini Municipality to pay all amounts that may hereafter, from time to time, become due and payable to me/us by the Ethekwini Municipality by electronically transferring the same to the bank mentioned above for the credit of my/our account detailed below. 2. I / we hereby certify that I/we am/are entitled to this refund and I/we understand that I/we will be liable to repay the amount refunded to the Municipality should it subsequently be established to the satisfaction of the City Manager or his authorized delegate that I am/we are not entitled to such refund.

3 3. I / we hereby agree that the Municipality will not be held responsible for any incorrect details supplied by myself / ourselves. 4. I/we hereby agree that I / we will be liable for any bank charges raised in the event of any electronic banking transfer being unsuccessful due to incorrect information supplied. 5. I / we agree that refunds will be made ONLY to the account holder unless special circumstances exist as provided in the Municipality s Credit Control and Debt Management Policy 6. I/we the undersigned understand and agree that: Ethekwini Municipality shall not be liable to make good any loss I/we may suffer consequent upon such transfers pursuant to this authority and instruction. CREDIT TRANSFER TO ACCOUNT NUMBER _____HELD WITH THE MUNICIPALITY BANK ACCOUNT (EFT) OTHER _____(Specify) SECTION A: BANK ACCOUNT TO WHICH PAYMENTS ARE TO BE MADE NAME IN WHICH ACCOUNT IS HELD: _____ NAME OF BANK: _____ BRANCH NAME: _____ ACCOUNT TYPE: _____ BRANCH CODE: _____ ACCOUNT NUMBER_____ Important: Please attach a copy of a cancelled cheque or bank statement SECTION B: BEFORE RETURNING, THIS SECTION MUST BE COMPLETED BY YOUR BANK I/We confirm that the above information on the client s account at this bank is correct.

4 _____ _____ SIGNED ON BEHALF OF BANK CAPACITY _____ NAME BANK STAMP (dated) AR/01 v02/17 Ethekwini RevenueManagemement Florence Mkhize Building 251 Anton Lembede Street Durban 4001 Tel: 031 324 5000 Fax: 031 328 1002 E-Mail: Website: APPLICATION FOR REFUND The information as per the attached application form for refund will supersede any previous authorisation and instruction lodged with the Ethekwini Municipality. _____ _____ WITNESS NAME OF SIGNATORY Duly Authorised _____ _____ DATE SIGNATURE AND/OR _____ _____ WITNESS NAME OF SIGNATORY Duly Authorised _____ _____ DATE SIGNATURE ALL SIGNATURES ON BEHALF OF A COMPANY, ASSOCIATION, PARTNERSHIP OR OTHER BODY MUST BE VERIFIED BY ITS OFFICIAL STAMP. PROCEDURES AND PROCESSES Ethekwini Municipality implemented a system whereby, except in special cases, it is mandatory to refund customers via electronic funds transfer (EFT) rather than using traditional payment cheque system.

5 This system is considered to be more secure, and ensures timeous payments. In order to set up the necessary mechanism, all sections of this form must be fully completed. The following must accompany this application: The company s banking details on an authorised company letterhead (if the account is held by a Legal entity) A cancelled cheque A bank statement or letter from the bank confirming the details completed on this form A certified copy of ID (if the account is held by an individual) TAKE NOTE: The attached Application Form may be returned by Post or Email or may be hand delivered. Please return documents to any nearest Sizakala Service Center ORGANISATION STAMP CONVEYANCER STAMP FOR OFFICE USE Refunded R _____ CAPTURED BY: Per Cheque No: _____ AUTHORISED BY: Per Refund Voucher _____ DATE: Other _____ COPY FORWARDED TO (DEPT) COPY FORWARDED TO (DEPT.)